CA staffing ratios evoke anger 'tween RNs & LVNs - page 5
Big news on the California nursing ratios front. As California prepares to carry out its first-in-the-nation law telling hospitals how many nurses they must have on hand for patients, a bitter... Read More
Nov 23, '02<Legally, the issue points out an oversight in the new law big enough to push a gurney through.>
It may not have been an oversight at all. I dont remember if the original prososal said REGISTERED NURSE instead of "licensed nurse" - the law was passed in 1999 & the original bill was written by the RN union & submitted well before then. As is the case with every law, it goes thru a process & legislative committees & the final language passed into law is not exactly the same as what the original bill started out as.
I dont think this language was an oversight at all. I think the Governor & legislature bowed to the strong opposing lobbying by the hospital associations & deliberately worded it that way so the hospitals could have the option of using RNs to fill the staffing ratios or choose to fill them with less expensive LPNs if they wanted to. It may have been that the Governor would have refused to sign the law at all if the compromise in the language wasnt done. Theres a very good chance that the legislature deliberately put this vague language there to do exactly what its doing now.
Nov 23, '02originally posted by -jt
<i'm being taught that it is the rn who is responsible for everything and everyone ! we are told that everyone including lpns, work under our directions making us accountable for their actions. in the real world how does it work ?>
thats exactly how it is. and thats why the rns dont want the seius any-nurse proposal that will leave them responsible for the lpns 4 pts as well as their own 4 pts for a total of 8 pts for the rn.
before anyone gets nuts over the rn vs lpn debate, thats not even what this whole thing is about. the issue is the fact that rns have had to be responsible for a dangerously high number of pts. its unmanageable. end of story. it does not solve the problem to add more lpns. that still would require the rn to be responsible for the care of too many pts - hers and the lpns. asking for the rns pt load numbers to be reduced by having enough rns on staff is not a reflection on or denigration of the lpn. the focus of the issue is getting lost here.
most sbon generally states that lpns come under the direct supervision of rns; i just thought it was those rns in charge. how can they realistically think rns can have a full patient load of their own & also be equally responsible for the lpns' patient workload as well??? how can rns honestly & safely co-sign anyone else's work unless they've witnessed every single thing that was done to the patient???
that's impossible & ridiculous...why haven't rns fought that issue by now??? seems to me...that's a bigger issue here because lpns are licensed by the same sbon & are held responsible for it...why must another license be endangered or threaten should anything happen with the lpn & their patient??? the only thing that rns should be concern with is what advise or orders they've delegated to the lpns & whether or not they do it...not be responsible for the entire staff of that unit - cnas/mas included.
jmho - moe.
Nov 23, '02<The only thing that RNs should be concern with is what advise or orders they've delegated to the LPNs & whether or not they do it...not be responsible for the entire staff of that unit - CNAs/MAs included>
Yeah but in real life thats not how it works. For example:
RN working in the nursery - in the back room admitting a newborn tells the aide to take the babies out to the mothers for feeding. 30 minutes later 2 mothers discover they have the right cribs but the wrong babies in them. (They think its funny & not a problem - babies had the right bracelets on - just in each others cribs). Babies had been taken out of cribs during the shift to be fed, examined, changed, etc. Aides, LPN & MDs all were in the nursery during the shift. Babies were handled by lots of different staff. Anyone could have put the baby in the wrong crib. The RN was in another room with another pt & had nothing to do with it, but the RN was held responsible for the mix up because "shes the professional with the license", according to our VP of Nursing.
The RN wasnt even in the room when the aide took the babies to the mothers. There is no policy that says she must be there before the babies leave or that SHE had to check the cribs before they left the nursery. It says the person leaving the nursery with the babies has to. The aide didnt follow procedure & check the ID bracelt with the crib tag before leaving the nursery nor did she check the mothers ID bracelet with the babies when handing them over as she was required to do.
How did administration solve the problem? The aide got transferred to another unit. The RN got suspended for one day more than a full week - without pay - & then transferred to another unit. It was her fault even though she didnt violate any policy, she didnt do it, and wasnt even there. All she did was delegate to the aide to bring the babies to the mothers, but she ended up being held responsible for the aide not doing it correctly.
Of course we filed a grievance with the union & got the whole thing reversed for the RN, cleared her record & reinstated her pay, but it took a month after the suspension & pay loss to get it all resolved. The RN was told by her manager that she was a failure & not wanted back on the unit. Even though she won her grievance, the whole thing stressed the RN out so much, she refused the position that she had won back & went to work someplace else.
If we were not in a union, this whole incident would have been left as the RNs fault & failure, the suspension would have remained on her record, & she would be out more than a weeks pay for something she didnt do, and had no control of because she couldnt be in 3 places at once.
This is the kind of crap we're dealing with. Any wonder RNs dont want any part of hospitals anymore?
Nov 23, '02another example:
hospital Oncology unit - eve shift
1 experienced RN (and shes assigned to be in charge, too)
1 new grad RN
The nurses all get 8 pts each. But the RNs also have to provide certain hands-on care & all responsibility for the LPNs pts as well. So the LPNs have 8 pts each to help with. The 2 RNs really have 16 pts each. (and one of those RNs is a new grad, 2 weeks post orientation)
BTW, the charge RN was mandated to work ot that night..... 10 minutes before her first shift ended.Last edit by -jt on Nov 23, '02
Nov 24, '02originally posted by -jt
hospital oncology unit - eve shift
1 experienced rn (and shes assigned to be in charge, too)
1 new grad rn
the nurses all get 8 pts each. but the rns also have to provide certain hands-on care & all responsibility for the lpns pts as well. so the lpns have 8 pts each to help with. the 2 rns really have 16 pts each. (and one of those rns is a new grad, 2 weeks post orientation)
btw, the charge rn was mandated to work ot that night..... 10 minutes before her first shift ended.
it's absolutely ridiculous for the hospital in the above post to hold the rn responsible for what the mds/nps do within the nursey as they also have licenses...seems there should've been at least one rn in that part of the nursey at all time anyway...it was wrong for that particular hospital to have treated the rn in that fashion. the cna should've been written-up...if not suspended or worse...not the rn. the cna was oriented to the policy of the nursey & should've been held accountable for her actions. i'm not so sure as to report it to the sbon...but if some harm had of came to either of the infants...then i suppose she should've been report to them.
Nov 24, '02My SBON Newsletter arrived today. Consider the following reasons that nurses lost their license:
1. Administered Coumadin without checking labwork; did not administer blood in a timely manner. (Was this a shift from hell?)
2. Did not accurately document all assessments and treatments on her assigned patients. (Was this a shift from hell?)
It doesn't matter what the staffing mix is when there's an error. If there are errors reported to the SBON, you can lose your license. And, it isn't just the SBON, it's the lawyers and the courts you have to worry about. The RN is always considered the last line of defense against errors, anyone and everyone's errors. This law could have helped protect the patients as well as the nurses (both LPN and RN). When you're stretched too far, you're gonna make mistakes. When those mistakes happen, the RN AND the LPN will go down.
Nov 24, '02the thing that bothers me is that rns are fed-up with having to co-sign for the lpns' work...as rightfully so...both are licensed nurses that have their own scope of practice in which they have to follow. there are only a few things that the lpns can't legally do under their scope of practice that supposed to separate them from the rns right??? then why not have the rns do those things only for those patients & everything else that the lpns do is on them??? it really irritates me to read post suggesting that lpns can't do this or that because they're not "educated enough" to understand what it is they're doing...in other words...they have no ability to critical think. that's sooo absurd...if lpns can learn basic pathophysiology, med/surg & nursing fundamentals for their scope...why wouldn't it be possible to teach the rationales behind them as well...instead of letting many just go about the task of it. that'll definitely free-up a lot of rns.
trust me, i'm not trying to make this out to be about rns vs. lpns at all. i'm just looking at other ways of coming-up with solutions to a very old problem...one that should've been addressed years ago...when lpns were first introduced into the nursing profession.
just a thought - moe.Last edit by SKM-NURSIEPOOH on Nov 24, '02
Nov 24, '02Aw, heck, SKM. I don't wanna get flamed. I don't want to turn this thread into an LPN vs. RN debate! But, I'm afraid if I open my big mouth, that's exactly what will happen just for saying what I believe. So, everybody who wants to flame me, would you please just count to 10 and realize that I'm speaking MY opinion and it doesn't have to be taken personally?
OK. Disclaimer out of the way. I was an LPN for over 20 years. The difference in education *is* the difference between an LPN and an RN. We do teach LPNs the rationale behind doing things. The technical skills performed correctly isn't the issue. It's all the training and knowledge behind it that's important. When I started my RN, I thought it would be a cakewalk, because I'd been an LPN for so long. It wasn't a cakewalk. Trust me, it was no cakewalk. If you'll excuse the immodesty, I consider myself a fairly bright, intelligent and articulate person. As an LPN, I always read on my own and studied nursing, and completed CEUs even though my state doesn't require them. Heck! I just didn't know what I didn't know. When I look back, it scares the crap out of me some of the things I did routinely as an LPN that I didn't have the faintest clue what I was doing! LPN is a vital and important role. Quite frankly, as an LPN I knew more of the technical side of things, even intuitively knew what to do, than a lot of the RNs I worked with. Some were just plain idiots and I have no idea how they managed to pass clinicals and the NCLEX. Still don't. As an LPN I worked in LTC where I was almost always the only licensed person in the building. I learned to think independently, problem solve, think critically, assess my residents, and almost always was the first nurse to know when something was going wrong with my residents. I will defend to the death anyone who says that an LPN can't out-perform an RN and anyone who believes that an LPN isn't just as capable of doing the job! But, the clincher is just that being an RN is so much more, with such a better foundation. My skills improved, my assessments improved, my problem solving improved, I became even a better nurse. I just didn't know what I didn't know. Working on my RN humbled me to my knees when I began to realized what I didn't know. Now, it still scares the crap out of me sometimes because there's just so many factors that go into patient care. I still cry about a little lady that went into CHF and died before we could get her to the hospital. I was an LPN in school for my RN at the time. The very next week, we were doing heart sounds and I KNEW that if I'd have just known those heart sounds a couple weeks earlier, I would have HEARD that she was getting into trouble long before she reached a crisis stage. But, to even understand what I was hearing, I had to learn the physiology, the route of blood, the different valves, and practice listening to the sounds . . . You just don't know what you don't know. Oh heck. No one reads long posts anyway.Last edit by Youda on Nov 24, '02
Nov 24, '02originally posted by youda
...i still cry about a little lady that went into chf and died before we could get her to the hospital. i was an lpn in school for my rn at the time. the very next week, we were doing heart sounds and i knew that if i'd have just known those heart sounds a couple weeks earlier, i would have heard that she was getting into trouble long before she reached a crisis stage. but, to even understand what i was hearing, i had to learn the physiology, the route of blood, the different valves, and practice listening to the sounds . . .
but i do hear ya youda...i'm currently in school for my rn as well, but i'm having a bit of a different experience than i guess you did though. i'm finding the nursing classes easy as i have the education from my lpn & experience to draw from. sometimes, i'm afraid for some of my classmates whom, no matter how much book knowledge they acquire, just can't seem to connect the theory with their clinical experiences. i help them-out as much as i can...without overstepping any bounderies.
but i guess my point is that rns shouldn't have to co-sign for another licensed nurses' work...that just crazy & i can't understand for the life of me why rns take it!!! if it was passed that rns are no longer are required to co-sign for the lpns, then would they welcome them back into the hospital mainstream???Last edit by SKM-NURSIEPOOH on Nov 24, '02
Nov 24, '02I'm fairly new to the site and maybe I should be worried about jumping into this "heated" thread but hear it goes-
I'm a RN and worked with LPNs in a tele unit in SC. They were a great group of nurses, a few taught me a thing or two. Having said that, I still had to cosign their assessments, hang blood, and give their IV meds in addition to caring for my own pt load. Surely this must be taken into consideration when considering nurse/pt ratios. I also would like to state that I have worked for 2 non-union hospitals and am currently at a union hospital and I wouldn't go back to the non union hospital. When our contract was negotiated 1 1/2 years ago, the nurses got 19% pay raise over the next 3 years and the charge nurses gained more control over pt flow on the floors ( ablility to close units to admits when staffing can't cover all the pts). I'd also like to add that I enjoy reading the threads and look forward to participating more in the future!
Nov 24, '02originally posted by skm-nursiepooh
...why shouldn't lpns be taught vital things like heart & lung sounds to the deepest degree??? it used to bother me when my instructors from my lpn program used to say...."this is this...but we won't really worry about that...because it's out of your scope." why not teach it anyway & make it part of the scope???
but i do hear ya youda...i'm currently in school for my rn as well, but i'm having a bit of a different experience than i guess you did though. i'm finding the nursing classes easy as i have the education from my lpn & experience to draw from. sometimes, i'm afraid for some of my classmates whom, no matter how much book knowledge they acquire, just can't seem to connect the theory with their clinical experiences. i help them-out as much as i can...without overstepping any boundaries.
but i guess my point is that rns shouldn't have to co-sign for another licensed nurses' work...that just crazy & i can't understand for the life of me why rns take it!!! if it was passed that rns are no longer are required to co-sign for the lpns, then would they welcome them back into the hospital mainstream???
what type of lvn's have you all been working with?
i understand lvn's scope of practice only allows us to do so much - so i understand some of the frustration's rn's are venting. but for rn's to blame lvn's for something that is totally out of our control - that's just ludicrous. do you get mad at your patient for having a cold? do you get mad at a seven year old for not conversing as a 15 year old? its the same analogy. upset about a limitation. i'm beginning to believe those same rn's who do all the whining (with no solutions or flexibility...of course) about "covering" lvn's would be the same rn's who would find something else to complain about if it wasn't the lvn "monkey-of-the-week" attack.
if an rn takes 5 minutes to hang an abx on a patient i'm assigned to...who's responsible to ensure the patient is tolerating the medication without adverse reactions? as a lvn, i am trained enough to apply my skills and know what treatment is required while i contact the on duty md and update my rn. i am responsible for this.
and fortunate for me, i was trained at a school by a group of rn's who aspired for us to go on to rn school. we where trained above the required curriculum because they new what type of lvn they would want by their side. our class fused about this initially, stating "we are not in rn school", but soon realized the extra education would make us that much more savvy once practicing as a nurse.
the way it is argued on most of these posts - i could take my lvn behind home while you "do all the work". should i start getting mad at cna's scope of practice, since they aren't pulling any medically helpful weight either? (that was a joke...no offense cna's!)
lets get it together, practice some sort of teamwork for each other, and move on. lvn's aren't going anywhere. get over it.
Nov 24, '02Wow....What type of LVN's have you worked with? I'm totally SERIOUS! You have described them as licensed dum-dum's, and I TOO would be worried working with them - Just as much as I'm worried when I have a registered dum-dum covering me.
Originally posted by -jt
The SEIU plan of a 1:4 ratio is a farce on the public.
When I give PO/PR medications, insert foley's, monitor labs, hang and monitor blood transfusion's, monitor vital signs and KNOW what they mean in relation to my patient - I AM A NURSE. (Heck - When I took the boards and passed I felt like a nurse!).
I think there's a HUGE difference state-to-state in how LVN's operate. I also think some RN's have experienced LVN's that may not have been very savvy or chose to do the minimum necessary...Which is the "tasks" assigned to their patient load. I'm sorry about that. But don't generalize all LVN's to be beasts of burdens. And before ANYONE says "This is not an LVN/RN thing"...Look back at how many posts put the burden of practicing RN's on LVN's. It becomes an LVN/RN thing because LVN's are continually put in the negative by those RN's who continue to insist we are of no value.
Originally posted by -jt
YOU will have only 4 pts. The RN will have her own 4 PLUS your 4.
I work in a small facility, 20 bed med-surg. I understand this makes a difference. I also work NOC's - So this adds to the difference. A usual shift there's 2 or 3 RN's and 1 or 2 LVN's.
Assignments are acuity based, and can look like this:
RN1 = 2 Patients, 1st admit, covering 2 LVN Patient
RN2 = 3 Patients, 2nd admit, covering 1 LVN "
RN3 = 3 Patients, 3rd admit, covering 1 LVN "
LVN = 4 Patients, transfer or 4th admit, 1 patients with no scheduled IV meds, 1 with blood transfusion, 1 with IV abx's Q6
Take into consideration:
Admissions during NOC shift varies, sometimes none.
This is a great night illustrated above!
Sometimes there are no scheduled tasks RN's have to intervene. I
Originally posted by -jt There is much more to that than just technical tasks like hanging your pts antibx. There are a lot of implications for me & the Pt's when Im trying to monitor your pts blood transfusions, manage your pts IVs, hang all your pts antibx, assess all your pts for changes and problems, keep ontop of whats happening with the full pt load that youre assigned to, and what you are doing, while Im trying to manage my own full pt load at the same time.
Maybe I've stumbled onto a small barrier here.
Of the RN's who have posted here, how many trust the nursing skills of the LVN's you currently work with? Do you feel you need to micro-manage them to assure your license isn't in jeopardy? Do you have control issues...in general?
(Sorry NMA!...Maybe I'll start a new thread with this question!)
Nov 24, '02I would like to address a couple things that have come up in this thread.
First Lois, if you happen to come back to this thread, RNs have not taken a thing from LPNs/LVNs. Secondly the way many LPNs practice now was not the way they practiced years ago. LPNs now have MORE responsibility than they used to have. My grandmother was an LVN in Texas as a young woman, and according to what she told me the duties she had were little more than what CNA's perform today. The only thing she did that was more was to pass PO meds. She did not assess patients, she did nothing with IV lines or drugs, what she did do was most of the hands on care of the physical needs of patients. Perhaps this was a Texas thing, but somehow I don't think so. Not too long ago we had an LPN on our unit that was an agency nurse. She has been an LPN for 32 years. I asked her a very specific question about one of her patients and she told me I would have to ask her nurse. I know I looked at her like she had two heads. I told her that according to the assignments she was the patients nurse. Yes, yes she answered, but she was the LPN not the Nurse. I stood there a bit dumbfounded trying to figure out if she had assessed the patient or what, or was I simply not understanding what she was getting at. So I asked her if she had assessed the patient or not. Yes, she had, however specific questions needed to be addressed to the Nurse that the patient had. It took me sometime to make her understand that she was the patients nurse and that she needed to know specifics about the patient. This nurse was highly uncomfortable with this scenario, she felt that all she was supposed to be doing was doing an inital assessment, giving that information to the RN who was assigned to her and that the RN was to be giving any specific information to whoever needed it. That is not the way my floor works, but trust me that is what this LPN expected. It must be understood that this LPN explained to me that she had been an LPN for 32 years, had not worked actively for awhile and did not feel comfortable having the responsibility for patients that we were giving her. This nurse did not return to our unit. Later I mentioned all this to my mom, who told me that was the way things used to be. The way most LPNs practice now is a new phenomonon, LPNs have the ability to do more than they used to do, there is nothing the RN has taken away. The issue has been muddied by corporates and facilities who have given LPNs more responsiblity because the reality is that the LPN commands less money. Of course it is a good deal to be able to get someone who is willing to do most of the same things that an RN does and be able to pay that person less money.
SKM, if LPNs were educated the same way as RNs than the education they received would make them an RN, not an LPN. There are differences in what is allowed in practice acts, and not only is that difference there, but even the Supreme Court makes RNs supervisors. The other reality to that is it is impossible for an RN to have their own patient load AND be able to adequately supervise what other nurses are or are not doing. Right now this is a real stuggle in my facility because we have a couple new LPNs that are struggling mighty hard as they transition from student to nurse, and it is causing the RN who is supposed to be their supervisor to consistantly fall behind in their own patient care, and yes the charge is helping in the situation, but it is not the only thing the charge has to deal with either.
One can always say there are good and bad, LPNs and RNs, both. I would wager that all of us have worked both LPNs and RNs that fit into either category. I think what too many LPNs don't stop to think is that most RNs are not saying that LPNs are stupid or incompetant because they are LPNs, what is being said is that the reality is that LPNs are to be supervised by an RN and that does increase our workload when an LPN is counted for patient assignments as if they are licensed to do all the same things an RN is licensed to do.
To me I see the problem as one in which the California Hospital Association is attempting to make this a nursing problem, instead of their problem, and unfortunately there are an awful lot of LPNs biting on it. I hear the refrain of, well of course I am a nurse and I am just as capable as the RN, how dare anyone say otherwise? It is not an issue of capability, it is an issue of license and responsiblity. And ultimately it is an issue of patient care. What I don't understand is how LPNs and RNs involved cannot see how the people who do not want to have to comply with this law are using the traditional infighting among ourselves to strengthen their positions. There are differences in the abilities of RNs and LPNs, for LPNs not to want to see that is akin to the physician assistant stating there are no real differences between them and the physician. No one fights about that, and no one has any difficulty in being able to ascertain what the difference is.
And yes, this does have to do with the SEIU. In my state the SEIU is attempting to be able to have techs, CNAs, PCAs, call them by whatever title you want, to be able to do more and more in the guise of it helping the RN in their patient loads. This has resulted in such assine things as LPNs not being able to put in IVs by their practice act, but there are CNA's doing it in the ER's of some hospitals. CNA's are putting in foley's, dropping NG tubes, and giving discharge education in some facilities. And by God this makes me angry! This is not happening in my facility, but I can freely say that if it were, I would quit. I am not going to be responsible for someone who is not educated to do this or licensed to do it either. It goes under the guise of the RN being able to "delegate" and "supervise" the problem is that the RN didn't get to decide if they wanted to "delegate" these things to a CNA. They were told this is the way it is. And the SEIU has been in the forefront of having this happen, at least in my state.
I am a firm believer if an LPN wants to have the same responsibilites as an RN than they should become an RN. In the same way that if I wanted to be able to do what a physician does, I would believe I should go back to school and become a physician. And personally I think that if LPN wants to see appropriate patient care than they would support the RNs on this, because the reality is that the RN will end up being responsible for the additional patients. Each LPN here has focused on the task oriented items that the RN has to do for the LPN, hanging IV, pushing the meds, hanging blood. What is not being thought of is that if I am responsible for the LPN patients ultimately, I am also responsible for the ultimate outcome. Just as jt illustrated in her example, the reality is the RN is the last line of responsiblity. It has always been so, it is not new, and it will always be so. Just like it will always be so that that I am required to follow the physician orders, not make up my own. Of course I may not agree with the physician, and twice in my career I have flat refused to follow an order, inviting the physician to come in and do it himself, but I do not have the ability to write my own order instead.
This issue should not be RN vs. LPN, but about patient care, the bills intent. But as long as there are LPNs who believe they have every right to be counted as an RN then there will be RN vs. LPN. I don't have the right to be counted as a physician, or even a physician assistant, and I would never believe I should. But unfortunately there will always be LPNs that believe they should be counted as an RN, despite the limitations of licensure because somehow or another they feel to do otherwise casts doubts on their abilities. The sad truth is that it has nothing to do with abilities but everything to do with license and education. Yes, education. I may have taken an anatomy class, but I sure as hell did not dissect a human being like a physician did, and will never pretend that I have the same intimate knowledge of the human body as the physician.
I am sure that there will be someone who will take offense to this post. Whatever. There is a difference in education, there is a difference in licensure and there is a difference between RN and LPN. Experience has taught me that there are drugs that should not be given together, experience has taught me much as I am sure experience also teaches LPNs. And even though that is the case, I still may not write whatever orders I may think is appropriate for the patient. That is the provence of the physician, not mine. Why should that be a difficult concept between RN and LPN?